63 Asian Nursing Research ❖ June 2009 ❖ Vol 3 ❖ No 2 ORIGINAL ARTICLE Loneliness, Depression and Health Status of the Institutionalized Elderly in Korea and Japan Oksoo Kim 1 *, RN, PhD, Young-Soon Byeon 2 , RN, PhD, Jung-Hee Kim 3 , RN, PhD, Emiko Endo 4 , RN, PhD, Makoto Akahoshi 5 , RN, PhD, Hiromi Ogasawara 6 , RN, MS 1 Professor, Division of Nursing Science, Ewha Womans University, Seoul, Korea 2 Professor, Division of Nursing Science, Ewha Womans University, Seoul, Korea 3 Full-time Lecturer, Department of Nursing, Woosuk University, Wanju-gun, Korea 4 Professor, Musashino University, School of Nursing, Tokyo, Japan 5 Professor, Miyazaki Prefectural Nursing University, Miyazaki, Japan 6 Associate Professor, Miyazaki Prefectural Nursing University, Miyazaki, Japan Purpose The purpose of the study was to describe loneliness, depression, and health status in Korean and Japanese institutionalized elderly and explore differences between the countries. Also this study deter- mined predictors of depression in each group. Methods Elderly subjects, aged 65–98 (n = 184), were recruited from private nursing homes in Korea and Japan. Subjects were interviewed on health status, loneliness, and depression. Results Korean subjects had higher loneliness scores than Japanese. More Korean elderly had depres- sive symptoms than Japanese elderly. The mean GDS score of Korean elderly was 8.07 and that of Japan- ese elderly was 5.21. Korean elderly had less physical function, and perceived their general health to be poor. Loneliness and perception of general health were significant predictors of depression in Korean and Japanese subjects. Conclusion It is necessary to assess the levels of loneliness and depression of institutionalized Korean elderly and pursue an intervention to reduce these problems. [Asian Nursing Research 2009;3(2):63–70] Key Words aged, depression, health status, loneliness *Correspondence to: Oksoo Kim, RN, PhD, Professor, Division of Nursing Science, Ewha Womans University, 11-1 Daehyun-dong, Seodaemun-gu, 120750 Seoul, Korea. E-mail: OHONG@ewha.ac.kr INTRODUCTION In recent times, Korea has become an increasingly aging society. The elderly aged 65 and over consti- tuted about 9.7% of the Korean population in 2005 and numbers are expected to reach more than 24.1% in 2030 (Korea National Statistical Office, 2005). In Japan, people over 65 years of age constituted 20.0% of the population in 2005, with an anticipated 31.8% in 2030 (National Social Security, 2006). Received: January 28, 2009 Revised: February 4, 2009 Accepted: April 30, 2009 With the growing elderly population, an interest in physical and psychosocial health of the elderly has concomitantly increased. Depression in the elderly is a widespread prob- lem that is often not diagnosed and frequently under treated in Korea (Yang & Rim, 2006). The levels of depression of institutionalized Korean elderly are reported to be higher than those of community resid- ing Korean elderly (Oh & Choi, 2005). Previous findings suggest that depression can be associated with an increased risk of incidence of dementia and ideation of suicide in the elderly (Devanand et al., 1996; Vannoy et al., 2007). Therefore, healthcare providers need to recognize the factors associated with depression in the institutionalized elderly so they can be prevented. Loneliness and worsening health have been shown to be risk factors for depressive symptoms. Cacioppo, Hughes, Waite, Hawkley, and Thisted (2006) reported that higher levels of loneliness were associated with more depressive symptoms in older adults. In the process of aging, elderly people experience decreasing physical function and worsened general health (Crews & Zavotka, 2006; Martin, Bishop, Poon, & Johnson, 2006). It has been found that when considering psychosocial status such depression has a relationship with health (Jeon, Kim, & Kim, 2005). Residents in nursing homes have many physical and psychosocial needs, as elderly people who move into nursing homes experience a rapid change in their psychophysical balance (Degenholtz, Kane, Kane, Bershadsky, & Kling, 2005; Scocco, Rapattoni, & Fantoni, 2006). In Korea and Japan, the oldest son or daughter of a family traditionally takes care of their elderly par- ents. Today, this tradition is not being practiced to the same extent.The nuclear family is now the norm in Korea due to the rapid modernization of society. Many elderly people do not want to be a burden to their adult children. Therefore, the number of Korean elderly who want to enter nursing homes may in- crease in the future (Kim et al., 2005). The current knowledge is predominantly based on information from studies among community-dwelling elderly. Few studies have examined loneliness and depres- sion among nursing home clients. Both countries are the most rapidly aging soci- eties in Asia, and they share similar Confucian cul- tural traditions. Japan became an aging society earlier than did Korea, and the perspective on institution- alization of the elderly is more positive in Japan. Per- spectives on nursing home institutionalization may influence psychological status in elderly people. The purpose of this study was to investigate the differences in loneliness, depression, and health sta- tus in institutionalized Korean and Japanese elderly. In addition, the predictors of depression were exam- ined in both groups. METHODS Participants and procedures This study used a convenience sample of 184 insti- tutionalized elderly. Eighty-one participants were Korean and 103 were Japanese. All were at least 65 years of age. Participants were recruited from two pri- vate nursing homes in Seoul, Korea and eight private nursing homes in Miyazaki, Japan. Directors’ approval were obtained from the institutions. Elderly people who could communicate with interviewers were in- cluded in this study. The participants were assured of anonymity and confidentiality. All participants gave written consent to participate in the study. All information was collected through face-to-face interviews using the questionnaires in Korean and Japanese by the investigators. Measures Loneliness was measured by the Revised UCLA Loneliness Scale (RULS; Russell, Peplau, & Cutrona, 1980). The RULS is a 20-item, 4-point scale ranging from never (1) to often (4), with a total score of 20–80. The RULS includes 10 items that reflect satisfaction with social relationships and 10 that reflect dissatisfaction (Russell et al.). The scores of items that were positively worded were reversed before summing. Reported Cronbach’s alpha was .94 (Russell et al.). In a validity test, loneliness scores O. Kim et al. 64 Asian Nursing Research ❖ June 2009 ❖ Vol 3 ❖ No 2 65 Depression in the Elderly Asian Nursing Research ❖ June 2009 ❖ Vol 3 ❖ No 2 were significantly correlated with scores on the Beck Depression Inventory (r = 5.62). Construct validity of the Korean version of the RULS was established and the reported Cronbach’s alpha was .93 (Kim, 1997). In this study, Cronbach’s alphas were .91 and .86 in the Korean and Japanese sam- ples, respectively. Depression of the subjects was assessed by the Geriatric Depression Scale-15. The Geriatric Depres- sion Scale-15 (GDS-15) is a short, 15-item instru- ment specifically designed to assess depression in geriatric populations. Its items require a yes/no re- sponse. The Geriatric Depression Scale was first introduced by Yesavage (1992), and the short form (GDS-15) was developed by Sheik and Yesavage (1986). A GDS score of 6 or higher, up to 15 is indica- tive of “probable” depression. Concurrent and dis- criminant validity of the Korean version of the GDS was established and the reported Cronbach’s alpha was .90 (Bae & Cho, 2004). Sensitivity and speci- ficity of the Japanese version of GDS were reported (Schreiner, Hayakawa, Morimoto, & Kakuma, 2003). The reported Cronbach’s alpha was .85 in the Japanese GDS (Ide, 2000). In this study, Cronbach’s alphas were .81 and .80 in the Korean and Japanese sample, respectively. Physical functioning and general health perception was measured to evaluate health status using SF-36 Version 1 (Stewart, Hays, & Ware, 1988).The 36-item Medical Outcome Short Form Health Survey (SF-36) questionnaire was designed as a generic indicator of health status for the general population, which allows it to be self-administered. Physical Functioning is as- sessed using a 10-item, 3-point scale and the Gen- eral Health Perception is assessed using a 4-item, 5-point scale. For each scale, item scores are summed and transformed on a scale from 0 (worst possible health status) to 100 (best possible health status). Discriminant validity of the Korean and Japanese versions of SF-36 was established and reported Cronbach’s alphas were .93–.94 and .84–.86 in the Korean and Japanese version, respectively (Fukuhara, Bito, Green, Hsiao, & Kurokawa, 1998; Han, Lee, Iwaya, Kataoka, & Kohzuki, 2004). Cronbach’s alphas for Physical function were .93 and .92, and .66 and .84 for General Health Perception in the Korean and Japanese samples, respectively. Statistical analysis Statistical tests (two-tailed, p < .05) were carried out using SPSS (Version 15.0). Chi-square test and t-test were performed to show comparisons of Korean and Japanese elderly in demographic variables which in- cluded age, gender, education, marital status, the number of children and current illnesses. ANCOVA was conducted to assess a difference between Korean and Japanese elderly in study variables (loneliness, depression and health status). Age, gender, educa- tion and current illness were controlled as covari- ates. Simultaneous multiple regression analysis was used to test loneliness, physical function and general health perception had significant effects on depres- sion in each group. RESULTS General characteristics Table 1 shows a comparison between the background variables in Korean and Japanese elderly (age, gen- der, education, having a spouse, the number of chil- dren, and current illness). A significant difference was found between the average age of Korean el- derly compared with that of the Japanese (t = –3.07, p = .00). The majority (93.8%) of Korean older adults institutionalized in Korean nursing homes were female, while 74.8% were female in Japanese nursing homes. Concerning educational level, the majority of the Korean elderly (90.0%) graduated from elementary school or lower, while the Japanese elderly who graduated from high school or higher constituted the greatest percentage in this variable. More Korean subjects reported having current ill- ness (96.3%; χ 2 = 6.85, p = .01) compared with Japanese (84.5%). No significant group differences were found for having a spouse and children. Level of loneliness, depression, and health status There was a significant difference in the level of lone- liness between Korean and Japanese participants O. Kim et al. 66 Asian Nursing Research ❖ June 2009 ❖ Vol 3 ❖ No 2 (Table 2). Korean subjects had higher loneliness scores than Japanese (t = 24.53, p = .00). In terms of loneliness, moderate loneliness was the most prevalent in the loneliness group of Korean elderly, while low loneliness was most com- mon among the Japanese elderly. In depression, the mean GDS score of Korean el- derly was 8.07, while that of Japanese elderly was 5.21. However, there was no significant mean differ- ence in the level of depression between the Korean and Japanese (t = 2.25, p = .14). Notably, 66.7% of the Korean elderly scored ≥ 6 on the GDS, which in- dicates the need for further evaluation. This preva- lence of depressive symptoms was higher than the rate of 41.7% among the Japanese elderly ( χ 2 = 10.80, p = .00). Fifty eight percent of the Japanese elderly were in the not depressed group. The Korean elderly had less physical function (t = 6.66, p = .01) and poor general health percep- tion (t = 5.69, p = .02). Multiple regression analysis Simultaneous multiple regression analysis was used to test which variables had significant effect on depres- sion in each group. In these models, loneliness, phys- ical functioning, and general health perception were entered as independent variables. Table 3 shows that loneliness and general health perception were significant predictors of depression for the Korean and Japanese subjects. Regression analysis indicated that 55% of the variance in depression scores was explained by these variables in the Korean elderly. DISCUSSION The purpose of this study was to identify the pre- dictors of depression in Korean and Japanese elderly subjects dwelling in nursing homes by comparing each group’s depression, loneliness, physical function, and health perception. Table 1 Differences in Background Characteristics in the Korean and Japanese Groups Korean (n = 81) Japanese (n = 103) n (%) n (%) t or χ 2 p Age (M ± SD) 79.47 ± 6.28 82.57 ± 7.21 −3.07 .00 Gender 11.77 .00 Male 5 (6.2) 26 (25.2) Female 76 (93.8) 77 (74.8) Education 73.87 .00 Elementary school or less 72 (90.0) 27 (26.2) Middle school 4 (5.0) 31 (30.1) High school 4 (5.0) 45 (43.7) Having a spouse 1.05 .27 Yes 15 (19.2) 14 (13.6) No 66 (80.8) 89 (86.4) Number of children 4.21 .24 None 21 (25.9) 20 (19.4) One 11 (13.6) 19 (18.4) Two 12 (14.8) 25 (24.3) Three or more 37 (45.7) 39 (37.9) Current illness 6.85 .01 Yes 78 (96.3) 87 (84.5) No 3 (3.7) 16 (15.5) 67 Depression in the Elderly Asian Nursing Research ❖ June 2009 ❖ Vol 3 ❖ No 2 In this study, the level of loneliness in the Korean elderly was higher than that of the Japanese elderly. Furthermore, the level of loneliness that Korean institutionalized elderly experienced was higher than that of the Korean community-dwelling el- derly (Kim, 2006). This may be because Korean insti- tutionalized elderly do not have as many friendly relationships, compared with community-dwelling elderly, due to limitations in their social activities (Sung, 2006). One reason why the level of loneli- ness of the Korean elderly is higher than that of the Japanese is that Koreans view nursing homes very negatively. However, in Japan many view living in nursing homes as positive and may be seen as better than living in their own homes (Tsugaruya, 2004). When classifying the level of depression, 66.7% of Korean elderly and 41.7% of Japanese elderly were depressed in this study. Jones, Marcantonio, and Rabinowitz (2003) reported that 20.3% of United States elderly dwelling in nursing homes were depressed, and Sherina, Rampal, Hanim, and Thong (2006) reported that 54% of the institution- alized elderly in Malaysia were depressed. Mean- while, the level of depression of the Korean elderly is higher than that observed in the United States and Malaysia. In general, Koreans tend to consider living in nursing homes very negatively. A study by Kim et al. (2005) revealed that 62% of adult chil- dren did not intend to send their elderly parents to nursing homes. The reason given was that they Table 2 Differences in Loneliness, Depression, Physical Function and General Health Perception in the Korean and Japanese Groups Korean (n = 81) Japanese (n = 103) M ± SD or n (%) M ± SD or n (%) t or χ 2 p Loneliness 48.79 ± 9.39 36.35 ± 10.58 24.53 .00 Low 4 (6.1) 52 (50.5) .00 Moderate 34 (51.5) 38 (36.9) Moderately high 24 (36.4) 11 (10.7) High 4 (6.1) 2 (1.9) Depression 8.07 ± 3.84 5.21 ± 3.52 2.25 .14 GDS score < 6 25 (33.3) 60 (58.3) 10.80 .00 GDS score ≥ 6 50 (66.7) 43 (41.7) Physical function 55.22 ± 16.65 69.75 ± 20.45 6.66 .01 General health perception 53.57 ± 15.15 68.98 ± 15.15 5.69 .02 Note. Because the comparison of loneliness group was performed by Fisher’s exact test, χ 2 was not presented. Table 3 Multiple Regressions Predicting Depression in the Korean and Japanese Groups Predictors Korean Japanese b tpFR 2 b tpFR 2 Loneliness .61 5.83 .00 23.17 .55 .36 4.02 .00 13.33 .29 Physical function −.02 −.14 .89 −.14 −1.35 .18 General health perception −.22 −2.03 .05 −.27 −.21 .05 believed that adult children should support their elderly parents. The Korean elderly were found to have worse physical function and health status than the Japanese elderly. This corresponds to the results of a study that compared Korean community-dwelling elderly with Japanese community-dwelling elderly (Choi, Chae, Kim, & Jeon, 2006). This study found that the perceived health status of Korean elderly was lower than Japanese elderly. In Korea, when the el- derly are healthy or economically stable, they tend not to dwell in nursing homes (Choi, 2002). Depression was influenced by loneliness and general health status in Korean and Japanese elderly. This corresponds to the study results of Cacioppo et al., (2006) and Tiikkainen and Heillinen (2005). These studies examined United States middle-aged and elderly populations and reported that as the level of loneliness increased, both populations became more depressed. In a study by Rauch, Morales, Zubritsky, Knott and Oslin (2006) that targeted the Japanese elderly, it was revealed that the elderly who perceived themselves not to be in good health were more depressed. According to the results of a study by Lee and Kim (2005) concerning Korean low-income elderly, health status affected depres- sion levels. The results of these two studies men- tioned above indicate that poor health affects depression levels. Aging has occurred in Japanese society earlier than in Korean society. Overall, the view regarding institutionalized elderly is more open and positive in the Japanese society. Hence, perceptions concern- ing institutionalized elderly are more positive in Japan. In Korea, when adult children cannot look after their elderly parents in their homes or when the elderly do not have enough money to support themselves, nursing homes are frequently used. Accordingly, Koreans are not likely to encourage their elderly parents to dwell in nursing homes because of Korean traditional filial piety. However, it is likely that the number of elderly dwelling in institutions such as nursing homes will increase because the number of elderly people in Korea is rapidly increas- ing. Therefore, it is necessary to assess the levels of loneliness and depression of institutionalized elderly and pursue an intervention to reduce these problems. In this study, the institutionalized duration was not considered as a factor affecting loneliness, depres- sion, and health status. In future studies, institution- alized duration may be considered as an influencing factor. In conclusion, elderly Koreans experience more loneliness than elderly Japanese. 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